The utility of the Sports Concussion Assessment Tool in hospitalized traumatic brain injury patients

Sargeant, M.; Sykes, EA; Saviour, M; Sawhney, Aarti; Calzolari, Elena; Arthur, J; McGoldrick, Adrian; Seemungal, Barry M.

doi:10.1177/2059700218808121

Cited by 6 publications

(9 citation statements)

References 28 publications

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“…The ABC score was not correlated with posturography performance in the vestibular-mediated condition ( r = −0.05, P = 0.80). These data confirm our earlier reports ( Sargeant et al , 2018 ; Marcus et al , 2019 ) that symptoms and signs are typically uncoupled in patients with acute TBI. Thus acute TBI patients with signs of an active peripheral vestibular condition (e.g.…”

Section: Resultssupporting

confidence: 93%

“…Remarkably, this is the first prospective study to assess balance and vestibular function in patients with acute TBI. We confirm with laboratory analyses, our previous cross-sectional clinical-bedside studies’ findings ( Sargeant et al , 2018 ; Marcus et al , 2019 ) that postural imbalance in acute TBI is both common (affecting over 80% of ambulant acute TBI patients) and displays a vestibular-dependent pattern. Our previous clinical report ( Marcus et al , 2019 ) showed that examination of acute TBI patients with intact peripheral vestibular functioning, follows a pattern reported by Brandt in acute peripheral vestibulopathy patients ( Brandt et al , 1999 ), i.e.…”

Section: Discussionsupporting

confidence: 89%

“…Another common diagnosis in acute TBI patients is benign paroxysmal positional vertigo (BPPV), affecting ∼40% of cases in our acute cross-sectional series ( Marcus et al , 2019 ). Consistent with our documented observation of a dissociation between objective and subjective features of vestibular dysfunction in acute TBI ( Sargeant et al , 2018 ; Marcus et al , 2019 ), we noted several acute TBI patients who denied vertigo sensation despite an obvious vestibular ocular reflex (VOR) response (e.g. during the positional manoeuvre used to diagnose BPPV), i.e.…”

Section: Introductionsupporting

confidence: 86%

“…There has been one cross-sectional study assessing instrumented measures of balance, in the subacute stage ( Klima et al , 2019 ) confirming manifest imbalance in subacute TBI. We also recently reported two separate cross-sectional clinical studies in ambulant acute TBI patients; one showing that 62% were unbalanced ( Marcus et al , 2019 ) of whom half did not report feeling unbalanced, and the other ( Sargeant et al , 2018 ), confirming the lack of correlation between objective signs of imbalance and vestibular symptom scores.…”

Section: Introductionmentioning

confidence: 68%

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Vestibular agnosia in traumatic brain injury and its link to imbalance

Calzolari

Chepisheva

Smith

et al. 2020

Brain

102

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Vestibular dysfunction, causing dizziness and imbalance, is a common yet poorly understood feature in patients with TBI. Damage to the inner ear, nerve, brainstem, cerebellum and cerebral hemispheres may all affect vestibular functioning, hence, a multi-level assessment—from reflex to perception—is required. In a previous report, postural instability was the commonest neurological feature in ambulating acute patients with TBI. During ward assessment, we also frequently observe a loss of vertigo sensation in patients with acute TBI, common inner ear conditions and a related vigorous vestibular-ocular reflex nystagmus, suggesting a ‘vestibular agnosia’. Patients with vestibular agnosia were also more unbalanced; however, the link between vestibular agnosia and imbalance was confounded by the presence of inner ear conditions. We investigated the brain mechanisms of imbalance in acute TBI, its link with vestibular agnosia, and potential clinical impact, by prospective laboratory assessment of vestibular function, from reflex to perception, in patients with preserved peripheral vestibular function. Assessment included: vestibular reflex function, vestibular perception by participants’ report of their passive yaw rotations in the dark, objective balance via posturography, subjective symptoms via questionnaires, and structural neuroimaging. We prospectively screened 918 acute admissions, assessed 146 and recruited 37. Compared to 37 matched controls, patients showed elevated vestibular-perceptual thresholds (patients 12.92°/s versus 3.87°/s) but normal vestibular-ocular reflex thresholds (patients 2.52°/s versus 1.78°/s). Patients with elevated vestibular-perceptual thresholds [3 standard deviations (SD) above controls’ average], were designated as having vestibular agnosia, and displayed worse posturography than non-vestibular-agnosia patients, despite no difference in vestibular symptom scores. Only in patients with impaired postural control (3 SD above controls’ mean), whole brain diffusion tensor voxel-wise analysis showed elevated mean diffusivity (and trend lower fractional anisotropy) in the inferior longitudinal fasciculus in the right temporal lobe that correlated with vestibular agnosia severity. Thus, impaired balance and vestibular agnosia are co-localized to the inferior longitudinal fasciculus in the right temporal lobe. Finally, a clinical audit showed a sevenfold reduction in clinician recognition of a common peripheral vestibular condition (benign paroxysmal positional vertigo) in acute patients with clinically apparent vestibular agnosia. That vestibular agnosia patients show worse balance, but without increased dizziness symptoms, explains why clinicians may miss treatable vestibular diagnoses in these patients. In conclusion, vestibular agnosia mediates imbalance in traumatic brain injury both directly via white matter tract damage in the right temporal lobe, and indirectly via reduced clinical recognition of common, treatable vestibular diagnoses.

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Section: Resultssupporting

confidence: 93%

Section: Discussionsupporting

confidence: 89%

Section: Introductionsupporting

confidence: 86%

Section: Introductionmentioning

confidence: 68%

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Vestibular agnosia in traumatic brain injury and its link to imbalance

Calzolari

Chepisheva

Smith

et al. 2020

Brain

102

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“…Half of the cases with clinically obvious gait ataxia reported no balance problem which may lead to an under-recognition of vestibular dysfunction by clinical staff in acute TBI. This replicates a recent finding in a smaller group of acute TBI patients (with intracranial abnormalities on CT), where, using a sports concussion tool, we found no correlation between objective signs and symptoms of imbalance [9].…”

Section: Discussionsupporting

confidence: 91%

Vestibular dysfunction in acute traumatic brain injury

et al. 2019

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Traumatic brain injury (TBI) is the commonest cause of disability in under-40-year-olds. Vestibular features of dizziness (illusory self-motion) or imbalance which affects 50% of TBI patients at 5 years, increases unemployment threefold in TBI survivors. Unfortunately, vestibular diagnoses are cryptogenic in 25% of chronic TBI cases, impeding therapy. We hypothesized that chronic adaptive brain mechanisms uncouple vestibular symptoms from signs. This predicts a masking of vestibular diagnoses chronically but not acutely. Hence, defining the spectrum of vestibular diagnoses in acute TBI should clarify vestibular diagnoses in chronic TBI. There are, however, no relevant acute TBI data. Of 111 Major Trauma Ward adult admissions screened (median 38-years-old), 96 patients (87%) had subjective dizziness (illusory self-motion) and/or objective imbalance were referred to the senior author (BMS). Symptoms included: feeling unbalanced (58%), headache (50%) and dizziness (40%). In the 47 cases assessed by BMS, gait ataxia was the commonest sign (62%) with half of these cases denying imbalance when asked. Diagnoses included BPPV (38%), acute peripheral unilateral vestibular loss (19%), and migraine phenotype headache (34%), another potential source of vestibular symptoms. In acute TBI, vestibular signs are common, with gait ataxia being the most frequent one. However, patients underreport symptoms. The uncoupling of symptoms from signs likely arises from TBI affecting perceptual mechanisms. Hence, the cryptogenic nature of vestibular symptoms in TBI (acute or chronic) relates to a complex interaction between injury (to peripheral and central vestibular structures and perceptual mechanisms) and brain-adaptation, emphasizing the need for acute prospective, mechanistic studies.

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